Fillable NJPB INCIDENT REPORT Include a copy of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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NJPB INCIDENT REPORT Include a copy of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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U.S.A. forms for State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General

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Page 1
PB Form #1
Revised 11/18
NJPB INCIDENT REPORT
Date of report: ____________________________
Date of incident: ___________________________
Send To: From: (Identify Person Reporting Incident)
State of New Jersey Name and Title: _______________________________________
Ofce of Drug Control-NJPB Unit
(Prescriber/Healthcare Facility/Printer/Pharmacist/Law Enforcement Agency/Other)
P.O. Box 45045 Address:_____________________________________________
Newark, New Jersey 07101 ____________________________________________________
Telephone: (973) 424-8159 or (973) 792-4240 Telephone number (include area code): ____________________
Fax: (973) 504-6326 Fax number (include area code): _________________________
E-Mail: CDS@dca.lps.state.nj.us
Include a copy of the RX (if available) along with a written narrative of the specic circumstances and
a copy of the police report (if reported).
Section I. - Personal Information Section II. - The Incident that occurred involves
________________________________________________
(Check Applicable Incident and as appropriate complete
Sections “III,” “IV” and “V” of this form.)
Misplaced (Lost) Forged
Stolen Altered
Damaged Counterfeit
Lost in Delivery Other (Describe below):
_________________________________________
_________________________________________
_________________________________________
(Name of Prescriber and Professional Degree or Name of Healthcare Facility
appearing on the involved NJPB form.)
(Professional License Number or Healthcare Facility Provider Number appearing on the
involved NJPB form.)
(Street address)
(City, State, County and ZIPcode)
Telephone number (include area code)
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Section III. - Description
The number of missing NJPB’s is estimated to be: ______________________ Batch number: _________________________
Serial number: ______________________________________
The name of the printer from whom the NJPB’s were purchased: ______________________________________________
The Incident involving the missing NJPB’s:
1.
Has not been reported to any law enforcement agency, governmental agency or professional licensing board.
2.
Has been reported to the following law enforcement agency, governmental agency or professional licensing board:
(1) Name: _________________________________________ (2) Name: _________________________________________
Address:________________________________________ Address:________________________________________
Telephone number (include area code): _______________ Telephone number (include area code): _______________
Person: ________________________________________ Person: ________________________________________
(3) Name: _________________________________________ (4) Name: _________________________________________
Address:________________________________________ Address:________________________________________
Telephone number (include area code): _______________ Telephone number (include area code): _______________
Person: ________________________________________ Person: ________________________________________
Please print clearly.
Page 2
Section V. - Additional Information
Section IV. - Details
A. List the perpetrator(s) involved in the Incident and provide each individual’s name, address, telephone number and date of
birth.
(1) Name: _________________________________________ (2) Name: _________________________________________
Address:________________________________________ Address:________________________________________
_______________________________________________ _______________________________________________
Telephone number (include area code): _______________ Telephone number (include area code): _______________
Date of birth: ____________________________________ Date of birth: ____________________________________
B. Was the person involved in the Incident arrested?
Yes No
If “Yes,” enter:
1. Name of law enforcement agency: _______________________________________________________________________
2. Address: ____________________________________________________________________________________________
3. Telephone number (include area code): ________________________________
4. Arresting ofcer or contact at agency: ____________________________________________________________________
C.
Check whether the medication involved in the Incident was a:
1.
C.D.S. (Enter name of controlled substance): ___________________________________________________________
2.
P.L.D. (Enter name of legend drug): __________________________________________________________________
D.
Was an attempt made to bill a Third Party Prescription Program for the medication involved in the Incident? Yes No
If “Yes,” enter the following information:
1. The name of the program administrator: ___________________________________________________________________
2. The telephone number (include area code) (if available): ________________________________
3. The patient’s I.D. number: ______________________________________________________________________________
4. The third party group number: ___________________________________________________
5. The policy number: _______________________________
6.
Was the third party administrator notied of the Incident?
Yes No
If “Yes,” enter:
The name of the person to whom the Incident was reported: ____________________________________________________
A.
Enter the name, address and telephone number of the pharmacy or pharmacies where the missing blanks were reported as
having been presented to be lled:
(1) Name: _________________________________________ (2) Name: _________________________________________
Address:________________________________________ Address:________________________________________
_______________________________________________ _______________________________________________
Telephone number (include area code): _______________ Telephone number (include area code): _______________
B. Please provide a copy of the RX (if available) along with a written narrative of the specic circumstances with this report.
Signature and title of the person preparing this Incident Report: _________________________________________________
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NJPB INCIDENT REPORT Include a copy of the (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 21 July 2020

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